Abstinence versus contraceptive use: the effect on pregnancy rates

In part one of this post, we examined the fallacy that provision of contraceptives increases the number of abortions. We presented strong evidence that couples do not abstain when no contraceptives are available. Now we turn to a related question about the efficacy of abstinence as a goal for reducing unintended pregnancy rates.

It is clearly true that if couples did abstain from sex when contraceptives were not available, unintended pregnancies would be less frequent and abortions would surely decline. But how many people would have to abstain to achieve the fertility reduction achieved by couples using contraceptive methods? Are such levels of abstinence realistic?

Two imagined states:
Contraceptives-upon-Demand and Never-Never Land…

Let us imagine two states—call them Contraceptives-upon-Demand (CUD) and Never-Never Land (NNL)—each with a population of 1,000 couples who do not want to become pregnant this year. In Contraceptives-upon-Demand, everyone uses condoms and, just like condom users everywhere, not everyone uses condoms effectively and consistently. Based on the typical use failure rate for condoms, in CUD 180 women would have unintended pregnancies in a year. In Never-Never Land, there are no contraceptives, so abstinence is the only way to prevent pregnancy. How many couples in Never-Never Land would have to abstain to achieve the same rate of pregnancy as condom—using CUD? 788 out of 1,000. [1]

Now if the women in CUD used more effective methods of contraception like oral contraceptives (OCs) or intrauterine devices (IUDs), they would have far fewer pregnancies than when they were relying on condoms alone—90 pregnancies in a year if women used OCs and just 2 pregnancies if women used IUDs. [2] Back in NNL, 89% of the 1,000 couples would have to abstain for the year to match the oral contraceptive pregnancy rate in CUD, and all but two of the couples would have to abstain in order to match the pregnancy rate of those using IUDs in CUD.

There is no place or program that has achieved these levels of abstinence. Among all women, teenagers may be the most likely to be able to abstain because few are married or in steady relationships, and the frequency of intercourse is lower than for women in their twenties and thirties. But even teenagers enrolled in abstinence programs have not achieved a 79% abstinence rate. The programs that most effectively promote abstinence-only messages have not been shown to reduce sexual activity among teens and achieve only about a 50% abstinence rate. (See Cagampang et al., 1997; Kirby, 2007; and Trenholm et al., 2007.)

…and two actual states: California and Texas

Returning to our state examples, we could have called Contraceptives-upon-Demand and Never-Never Land, California and Texas. In 1988, both California and Texas had among the highest teen pregnancy rates in the country. California has had a state family planning program since the 1970s. In 1997, California expanded access to contraceptives to nearly all teenagers as part of the Family PACT Program. Family PACT now serves almost 1.8 million low-income women and men each year, including over 300 thousand teenagers.

Texas has no state family planning program but does have contraceptives available through its Title X program. But Title X in Texas serves only an estimated 15% of women in need (much lower than the national average of 27%). Access to contraceptive services is poor in Texas: a 17-year-old who wants to use contraceptives in Texas would have to find Title X services and even then would need her parents’ permission to get contraceptives. Public Health Institute data show the effects of these two approaches on the teen birth rate.

The debate over public support for family planning should be based in evidence. The evidence is strong that expanding access to effective contraceptive methods is the best approach to reducing unintended pregnancy and the demand for abortion.

This is just a crude calculation which actually underestimates the percentage of couples who would have to abstain. We took the typical use pregnancy rate for each contraceptive method and calculated what percentage of couples could continue to have sex without contraception (at an 85% annual pregnancy rate) to achieve the same number of pregnancies. It underestimates abstinence rates because 85% refers to the percentage of women who have at least one pregnancy within a year. Couples who do not abstain can have more than one pregnancy each year, especially if some pregnancies end in abortion.

Very interesting analysis. After 30+ years as a child and adolescent psychiatrist, what I find most effective in preventing pregnancy (and according to studies, encouraging teenagers to delay sex) is the middle path between abstinence and condoms on demand – comprehensive information about the nitty gritty – what causes pregnancy and how it can be prevented. This would include information about how to use condoms effectively. The big problem many teenagers have is that the boy doesn’t know to pull out right away and the condom slips off when he goes soft. My clients don’t like it when I talk about this stuff, but they rarely get pregnant.

Those, like myself, who view sexuality as having a spiritual component that is only properly accessed through a life long sacramental commitment cannot acquiesce to a statistics argument. Much like abortion always being wrong due to the intrinsic value of human life, sexual activity without that commitment (marriage) is a right/wrong equation, not one of methodology.

If banning guns but passing out knives leads to fewer murders, it makes the remaining knife based murders no less acceptable or tolerable to moral human beings and in fact puts blood (guilt) on the society for giving an imprimatur on murder.

The elimination of suffering is not the highest good, rather right behavior in all circumstances should be the guide for a society’s desideratum. Only then can a society grapple with the problem of evil and the causes. The course of water will never get you to that end.

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About ANSIRH

Advancing New Standards in Reproductive Health—ANSIRH—works to ensure that reproductive health care and policy are grounded in evidence. ANSIRH’s multi-disciplinary team includes clinicians, researchers and scholars in the fields of sociology, demography, anthropology, medicine, nursing, public health, and law. ANSIRH is a program of the Bixby Center for Global Reproductive Health. Read more on ANSIRH’s website.